but could trigger mania as well43. In a recent paper, the use of sleep deprivation was administered in conjunction

with other chronotherapies, such as bright light therapy, and sleep advance phase. Bright light therapy was

administered the day after the sleep deprivation night for three consecutive days, while following a sleep deprivation

night subjects were exposed to sleep phase advance, to reset the sleep time around 10 PM. The combination of these

therapies was shown by the authors of the paper to have a fast and long-lasting anti-depressive effect without

triggering mania44.

Morning bright light therapy was attempted in depressive phases of BD, but in the vast majority of cases it would

trigger mania; however, a higher dose of midday bright light was found beneficial45.

Similarities between Ayurveda knowledge and new western traditional medicine approaches to BD

The first striking feature that surprises us when comparing the Ayurvedic description of unmada and the more recent diagnosis and classification of BD symptoms is the similarity between these two disciplines, developed in times so far from each other. Typical vata symptoms that have been described in ancient texts and have a counterpart in modern psychiatric diagnosis methods (e.g. DSM-IV) include, for example, continuous irregular speech, excessive talking or “pressure of speech” (satatamaniyanam ca gira and bahubhasita), hyperactivity and inappropriate behaviors such as excessive smiling, laughing, or dancing (abhiksnasmitahasitanrtyagitavadi), abusive and

dangerous behavior (vikrosa). Similarly, pittaja unmada symptoms such as impatience (amarsa), anger (krodha), violence (samrambhaschasthane), raised temper (rosa), sleeplessness (vinidra) are also present in the description of BD in the DSM-IV. Both vata and pitta symptoms are translated as manic manifestations of the disease. Also when considering kaphaja unmada symptoms it is possible to find similarities to the DSM-IV diagnosis criteria for BD, such as psychomotor retardation (stillness and sluggishness) (alpacankramana and sthanamekadese), lacking of energy (alpamati), hypersomnolence (swapnanityata)46.

The main goal of chronobiology is to re-establish a physiological and personal routine in sleep and eating behaviors. This is of particular importance for a disorder as highly variable as BD in which, depending on the phase of the disease, a patient may sleep less than 3 hours per night and forget to eat, or oversleep and overeat. The same principles are considered fundamental in the management of vata-driven pathologies when samana vayu is vitiated, focusing the treatment by also improving a constant routine around sleep and eating habits20.

In addition, in BD, Ayurvedic principles can offer a mechanism behind the validity and failure of certain chronotherapies. Sleep deprivation therapies used to treat depression were demonstrated to be a non-effective treatment for BD, triggering mania in a high percentage of volunteers, despite the finding that in major depression the treatment did not have side effects. Effective vata-reducing practices improve rest and sleep time, therefore sleep deprivation would exacerbate vata vitiation and symptoms. On the other hand, BD symptoms were ameliorated when patients were treated with 14 hours of bedtime in the night in total darkness, that can be considered a vatapacifying

technique, since people with vata vitiation are extremely sensible to stimuli (“loud music or noise”20). A similar example is the bright-light therapy used in treating BD patients that was found to be effective to treat depression without triggering mania if administered during mid-day, a moment of high pitta, important for properly digesting the light.

Conclusions

All reported evidence points out that the proper management of the life-threatening disease BD is still a challenge for modern psychiatry; however, the new concept of chronobiology is helping physicians with novel therapies, such as dark and light therapy, sleep deprivation and sleep phase advance therapy. Similar concepts of ad-hoc life-style changes were already suggested from early in the Common Era by Ayurvedic practitioners for the treatment of specific disorders. The ancient, yet current, Ayurvedic knowledge can be extremely important for the proper application of chronotherapies, resulting in a more personalized and affordable treatment to counterbalance subjective imbalances in BD. Taken together, chronotherapies and Ayurveda could be a new keystone in the